Taking CAR T Cells From First-in-man Trials To Marketing Authorisation – The View From A Pharmaceutical Developer Stanley R. Frankel, M.D. Corporate Vice President, Global Clinical R&D Head, Immuno-Oncology Celgene Corporation Adjunct Associate Professor of Medicine Columbia University College of Physicians and Surgeons November 16, 2016
Disclaimer • The views and opinions expressed in this presentation and discussion are not necessarily the views of Celgene Corporation, its corporate partners, or that of Columbia University. 2
Design Characteristics To Define A Pharmaceutical Product Profile • Target • Mechanism of Action • Pharmaceutical properties – Specificity – Potency/Affinity • Dose selection – Starting dose – Optimal/Maximal tolerable dose • Schedule/Duration • Risk benefit profile – Clinical activity in a defined population – Adverse events • Regulatory comparators for unmet medical need • Commercial competition and potential differentiation 3
Taking CAR T Cells From First-in-man Trials To Marketing Authorisation – The View From A Pharmaceutical Developer • Chimeric Antigen Receptor modified autologous T cells directed against CD19 have the potential to provide cure. • The curative potential of CD19 directed CAR T cells is balanced by considerable safety risks that continue to be defined and addressed. • The substantial clinical activity and considerable safety risks provided by CD19 directed CAR T cells and rapid advances in clinical development by multiple sponsors challenge the regulatory status quo. • Despite some convergence in observed biology, each construct, manufacturing process, clinical protocol, disease state are different • Rapid scientific advances in altering the design and composition of CAR T therapies pose substantial regulatory and development challenges • Iterative improvements in CAR T design, manufacturing, and therapeutic management are anticipated but the regulatory path to allow for innovation may require legislative changes 4
CD19 CART Products JCAR015 and JCAR017 Manufacturing Process Flow Multiple, complex variables for CMC complicate development T cells isolated, T cells activated, and CAR T cells expanded CAR T cells infused PBMCs obtained from patient via transduced with viral and conditioned to into patient after JCAR015: CD4+/CD8+ vector therapeutic dose, lymphodepleting standard together formulated and leukapheresis chemotherap y JCAR015: CAR gene via cryopreserved collection JCAR017: CD4+ & CD8+ gammaretrovirus separately JCAR017: CAR/EGFRt genes via lentivirus QC/QA release 5
Defined Composition for Improved Potency Activity of T cells in Mice with Human Lymphoma Xenografts CD8 and CD4 T Cell Subsets Effector T cells (T E ) Memory Stem Cell Naïve T cell Central Memory (T CM ) Effector Memory (T EM ) (CD45RO+, CD62L-, CD28-. (CD45RA+CD62L+ (CD45RA+CD62L+, (CD45RO+CD62L+ (CD45RO+CD62L-,CD28+/- Perforin hi, Granzyme hi ) CD28+,CD95+) CD28+CD95-) CD28+, CD95+) CD95+) CAR-T cell dose 1x10 6 CD8 CM /CD4 CD8 CM Day PBMC (Defined Ratio) 26 47 Sommermeyer, D., et al. Leukemia , 2016. 6
Optimizing T cell composition The right T cell populations matter Patient-Derived PBMC Common Expansion T H Methods T CM T H T CM T H T H a CD3/ a CD28 & cytokines T H T CM T CM T CM T H T H T CM JCAR014/JCAR015/JCAR017 Provides: • Defined cell products • Higher % CAR T cells T H T CM • Permits lower cell doses T H T H T CM T H T CM T H • May improve efficacy T H T CM T CM T H T H T H T CM T H T CM • May have lower toxicity T CM T H T CM T H T H T H T H T CM T CM T H T CM T H 1) CD8 + T CM to target tumor T CM T H T H T CM T CM T H T CM 2) CD4 + T cells to promote T CM T H T H T CM T H Terakura, S., et al. Blood , 2012. T CM T CM T H Stemberger C., et al. PLoS One , 2012. Sommermeyer, D., et al. Leukemia , 2016 7
Efficacy and Safety Data Available Academic Data in R/R ALL Product Candidate JCAR014 JCAR015 JCAR017 r/r Adult ALL r/r Adult ALL r/r Pediatric ALL N = 51 Trial N = 36 N = 37 Response Evaluable = 50 Evaluable = 34 (1) Evaluable = 33 (3) Toxicity Evaluable = 51 (2) Complete Response / Remission 100% 82% 91% Complete Molecular Remission 94% 67% 91% Severe Cytokine Release Syndrome 21% 28% 27% Severe Neurotoxicity 26% 29% 18% (1) Turtle, Abstract 102, ASCO 2016; (2) Park, Abstract 7003, ASCO 2016; (3) Gardner, Abstract 3048, ASCO 2016 Median follow-up: 6 months (1-45 months) Cumulative follow- up: 20/45 (44%) patients with ≥ 6 months of follow up 9/45 (20%) patients with ≥ 1 year of follow up 8
Cytokine Release Syndrome & Neurological Toxicities By Baseline Disease Burden: MSKCC R/R Adult ALL Morphologic Disease Minimal Disease (N=31) (N=20) Severe CRS 13 (42%) 1 (5%) Grade 3/4 Neuro Toxicities 11 (35%) 4 (20%) Severe CRS & Gr 3/4 Neuro Tox 7 (23%) 1 (5%) Severe CRS or Gr 3/4 Neuro Tox 17 (55%) 4 (20%) 4 (13%) ¶ Grade 5 Toxicity Management Treated with Tocilizumab 12 (39%) 0 (0%) Treated with Steroids 11 (35%) 1 (5%) Treated with Toci & Steroids 10 (32%) 0 (0%) ¶ All pts received a higher dose (3x10 6 CAR T cells/kg): 2 pts with sepsis/multi-organ failure; 1 pt had seizure, but unknown cause of death • Use of Tocilizumab and/or Steroids had no impact on RFS or OS. Park et al, ASCO 2016: 7003
MSKCC Adult R/R B-lineage ALL Study Outcome: Complete Remission (CR) rates Morphologic Minimal Disease Disease N=20 (%) N=30 (%) CR Rate 23 (77%) 18 (90%) [58 – 90] [68 – 99] MRD negative CR Rate* 19/21 (90%) 14/18 (78%) [70 – 99] [52 – 94] Time to CR, Mean (SD) 20 days (9) 25 days (9) *MRD assessment was not available in 2 patients. After toxicity observed at 3 x 10 6 CAR T cells/kg; patients with morphologic disease dosed at 1 x 10 6 CAR T cells/kg; Minimal Disease patients remain dosed at 3 x 10 6 CAR T cells/kg Dose:toxicity relationship with disease burden as a variable demonstrated Park et al, ASCO 2016: 7003 10
Overall Survival by baseline disease burden: MRD-CR patients by post CAR-T HSCT Park et al, ASCO 2016: 7003 11
No Dose: Toxicity Relationship Observed CTL019 in CLL Presented By David Porter at 2016 ASCO Annual Meeting; Abstract 3009 12
No Dose:Response Relationship Observed? CTL019 in CLL Presented By David Porter at 2016 ASCO Annual Meeting 13
Dose:Response and Dose:Toxicity in Adult ALL CTL019 Presented By Noelle Frey at 2016 ASCO Annual Meeting; Abstract 7002 14
4192 Transcend NHL 001: Immunotherapy with the CD19-Directed CAR T-Cell Product JCAR017 Results in High Complete Response Rates in Relapsed or Refractory B-Cell Non-Hodgkin Lymphoma Jeremy S. A Abramso mson, MD 1 , Lia Palomba, MD 2 , Leo I Gordon, MD 3 , Matthew Lunning, DO 4 , Jon Arnason, MD 5 , Andres Forero-Torres, MD 6 , Tina M. Albertson, MD, PhD 7 , Victoria Shaw Exton 7* , Claire Sutherland, PhD 7* , Benhuai Xie, PhD 7* , Susan Snodgrass, MD 7 and Tanya Siddiqi, • No minimum absolute lymphocyte count (ALC) requirement for apheresis and no test expansion required. Lymphodepletion (fludarabine 30 mg/m 2 and cyclophosphamide 300 • mg/m 2 daily for 3 days) and JCAR017 given 2-7 days post- lymphodepletion at a starting dose of 5 x 10 7 CAR + T cells (DL1). • Single-dose and two-dose schedules are being evaluated. • 13 patients treated with JCAR017 with relapsed/refractory diffuse large B-cell lymphoma, • 2 or 14% experienced severe neurotoxicity both of which resolved • No patients experienced severe cytokine release syndrome. • In 11 patients available for efficacy, the overall response rate was 82% with a complete response rate of 73%. (ClinicalTrials.gov Identifier: NCT02631044) ASH Presentation December 5, 2016 15
Development Parameters To Be Defined Unique Challenges of Individual Living Cellular Products 16
Manufacturing Steps Are Complex • Cell Yield • Viability • Cell Selection • Activation • Transduction • Expansion • Process qualification • Formulation/fill/cryopreservation • Control of Materials: – Raw materials – Consumables – Biologic raw materials – Media/buffers/Virus 17
How Are Autologous CAR T Cells Different From Other Pharmaceutical Products? • This is an individual product • Manufacturing takes time; Release of product takes time • This is a living drug; dose infused is a starting point – Expansion and durability may not be fully proportional to infused dose – Limited dosing expected (1-2 doses for potential cure) – In vivo rate, peak, and persistent expansion likely more important that infused dose • Variability rather than consistency in biological behavior following infused dose is anticipated • Management of adverse events by corticosteroids may alter PK of CAR T cells • Rapidity and extent of CAR T cell expansion may be related to accessible target and tumor burden • Long term follow up and monitoring are required due to safety concerns related to viral transduction • Manufacturing costs are high; potential impact of manufacturing errors/failure is extremely high 18 • Chain of identify must have zero tolerance for failure
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